Motivating Latino Caregivers of Children With Asthma to Quit Smoking:
A Randomized Trial
The Warren Alpert Medical School of Brown University
and The Miriam Hospital
Elizabeth L. McQuaid
Rhode Island Hospital and The Warren Alpert Medical School
of Brown University
Scott P. Novak
S. Katharine Hammond
The University of California, Berkeley
Rhode Island Hospital and The Warren Alpert Medical School of Brown University
Objective: Secondhand smoke exposure is associated with asthma onset and exacerbation. Latino children
have higher rates of asthma morbidity than other groups. The current study compared the effectiveness of a
newly developed smoking cessation treatment with existing clinical guidelines for smoking cessation.
Method: Latino caregivers who smoked (N ? 133; 72.9% female; mean age ? 36.8 years) and had a child
with asthma were randomly assigned to receive 1 of 2 smoking cessation counseling interventions during a
home-based asthma program: (a) behavioral action model (BAM; modeled on clinical guidelines for smoking
cessation) or (b) precaution adoption model (PAM; feedback on the caregiver’s carbon monoxide level and
child’s secondhand smoke exposure using Motivational Interviewing). Counseling was delivered by a
for smokers to want to quit smoking to participate. Smoking cessation was biochemically verified and
secondhand smoke exposure was objectively measured through passive nicotine monitors. Results: Intent-to-
treat analyses showed that 20.5% of participants in the PAM condition and 9.1% of those in the BAM condition
were continuously abstinent at 2 months posttreatment (OR ? 2.54; 95% CI ? 0.91–7.10), whereas 19.1% of
participants in the PAM condition and 12.3% of those in BAM condition were continuously abstinent at 3 months
posttreatment (OR ? 1.68; 95% CI ? 0.64–4.37). Secondhand smoke exposure decreased only in the BAM
condition (p ? .001), an effect due to less smoking around the child among nonquitters in this condition. Asthma
morbidity showed significant decreases in the posttreatment period for the PAM group only (p ? .001).
Conclusions: Results provide support for targeting specific populations with theory-based interventions.
Keywords: smoking cessation, motivational interviewing, risk perception, secondhand smoke,
environmental tobacco smoke and asthma
Asthma prevalence and morbidity are much higher among
Latinos than among other racial and ethnic groups (Cloutier,
Wakefield, Hall, & Bailit, 2002; Lara, Akinbami, Flores, &
Morgenstern, 2006; Lieu et al., 2002). Secondhand smoke ex-
acerbates asthma symptoms (Mannino, Moorman, Kingsley,
Rose, & Repace, 2001), increasing school absence, emergency
care, and hospitalization (Mannino, Homa, & Redd, 2002).
Despite these risks, parents of children with asthma continue to
smoke at levels comparable to the general population of smok-
ers (Liem, Kozyrskyj, Benoit, & Becker, 2007).
Latinos represent the largest minority group in the United States
(14.5%; U.S. Census Bureau, 2004), among whom 16.5% cur-
rently smoke (Centers for Disease Control and Prevention, 2006).
Surprisingly, only four clinical trials have been specifically de-
signed to help Latino smokers quit smoking (Leischow, Hill, &
Cook, 1996; Nevid, Javier, & Moulton, 1996; Perez-Stable, Marin,
& Marin, 1993; Woodruff, Talavera, & Elder, 2002), and none of
these has focused on smokers who have children with asthma.
Many studies have focused on secondhand smoke reduction in
households with children with asthma (Hovell et al., 1994; Irvine
et al., 1999; McIntosh, Clark, & Howatt, 1994; Wahlgren, Hovell,
Meltzer, Hofstetter, & Zakarian, 1997; Wakefield et al., 2002;
Belinda Borrelli, Centers for Behavioral and Preventive Medicine, The
Warren Alpert Medical School of Brown University, and The Miriam
Hospital, Providence, Rhode Island; Elizabeth L. McQuaid, Department of
Child and Family Psychiatry, Rhode Island Hospital, Providence, Rhode
Island, and Department of Psychiatry and Human Behavior, The Warren
Alpert Medical School of Brown University; Scott P. Novak, RTI Inter-
national, Research Triangle Park, North Carolina; S. Katharine Hammond,
Environmental Health Sciences, School of Public Health, University of
California, Berkeley; Bruce Becker, Department of Emergency Medicine,
Rhode Island Hospital, and Centers for Behavioral and Preventive Medi-
cine, The Warren Alpert Medical School of Brown University.
Correspondence concerning this article should be addressed to Belinda
Borrelli, Centers for Behavioral and Preventive Medicine, The Warren Alpert
Medical School of Brown University, Coro Building–West, One Hoppin Street,
Suite 500, Providence, RI 02903. E-mail: Belinda_Borrelli@Brown.edu
Journal of Consulting and Clinical Psychology
2010, Vol. 78, No. 1, 34–43
© 2010 American Psychological Association
0022-006X/10/$12.00 DOI: 10.1037/a0016932
Wilson et al., 2001), but only one targeted Latino households
(Hovell et al., 1994). Two studies focused on smoking cessation
among caregivers of children with asthma, but neither of them
specifically targeted Latino smokers (Borrelli, et al., 2002; Groner,
Ahijevych, Grossman, & Rich, 2000).
In one smoking cessation study, Groner et al. (2000) found low
quit rates and no significant differences between two brief clinic-
based interventions in comparison with contact controls (less than
4% quit in each condition at 6 months posttreatment), concluding
that a more intensive and home-based intervention is required to
motivate smoking cessation among caregivers with children with
asthma. A previous study conducted by our research group (Bor-
relli, McQuaid, et al., 2005) also focused on smoking cessation
rather than secondhand smoke reduction, comparing the efficacy
of two theory-based smoking cessation interventions in the context
of a home-based asthma education program: the precaution adop-
tion model (PAM) (Borrelli et al., 2002; Weinstein, 1988; Wein-
stein, Rothman, & Sutton, 1998), which incorporates Motivational
Interviewing (MI) to deliver feedback on the level of smoke
exposure to oneself and to one’s child, was compared with the
behavioral action model (BAM), which draws on clinical guide-
lines and focuses on problem solving and building coping skills
(Fiore et al., 2000). Results indicated that the PAM group was
significantly more likely to achieve abstinence by 2 months post-
treatment than was the BAM group, but significant differences
dissipated by 6 months posttreatment (Borrelli, McQuaid, et al.,
2005; Borrelli et al., 2002). To date, no studies have focused on
smoking cessation among Latino caregivers of children with
The current study utilized the same design as our previous study
(Borrelli et al., 2002), but instead we proactively recruited an
all-Latino sample of caregivers who smoked and had a child with
asthma. The PAM intervention was refined through focus groups
to be consistent with the values and beliefs of the Latino culture
(familismo, personalismo, simpatia, described below; Marin &
Van Oss Marin, 1991). MI was the vehicle through which the
PAM intervention was delivered, because its person-centered fo-
cus is ideal for conveying risk messages in an empathic and
nonjudgmental manner, (Miller & Rollnick, 2002; Rollnick,
Mason, & Butler, 1999).
Both PAM and BAM interventions were delivered in the home
by a Latina health educator in either English or Spanish, depending
on the language preference of the participant. We hypothesized
that the PAM intervention would be more effective than the BAM
intervention in helping Latino smokers quit because (a) minority
and low-income smokers are less likely to personalize health risks
or focus on the benefits of quitting smoking (Bastida & Gonzalez,
1993; King, Borrelli, Black, Pinto, & Marcus, 1997); (b) most
smokers are aware of the dangers of secondhand smoke to their
children with asthma, yet continue to smoke; and (c) clinical
guidelines, which predominately focus on strategies to help smok-
ers who are ready to quit, may not be appropriate for smokers who
are proactively recruited, that is, not specifically seeking treatment
for smoking cessation. With regard to the latter, prospective par-
ticipants in our trial were told that they would receive the asthma
education program but that they did not have to want to quit
smoking in order to participate in the program; they only needed to
be willing to discuss their smoking. Therefore, smokers of varying
levels of motivation to quit were recruited, and we hypothesized
that a more motivational, rather than educational, approach was
needed for this population. The intervention content of both the
PAM and the BAM targeted smoking cessation, rather than expo-
sure to secondhand smoke, as a primary dependent variable,
though we report changes in both of these variables as well as
changes in asthma functional morbidity.
Our study has clinical and public health significance because it
(a) offers a single intervention that can affect multiple health
outcomes (i.e., pediatric asthma and parental smoking), (b) proac-
tively reaches smokers in their own homes who are less likely to
seek smoking cessation on their own, (c) provides intervention to
low-income Latino families whose children have high rates of
asthma, and (d) capitalizes on the teachable moment engendered
by the salience of the child’s asthma.
Participants were recruited from the following sources: hospital
emergency department (n ? 22), inpatient hospitalization setting
(n ? 5), outpatient asthma clinics and classes (n ? 24), Rhode
Island’s low-income health insurance plan (n ? 44), flyers (n ? 7),
Latino agencies and cultural events (n ? 2), other research projects
(n ? 6), other participants enrolled in the study (n ? 18), and other
sources (n ? 5). Prospective participants were told that in order to
be part of the program, they needed to accept asthma education
visits in their home and discuss their smoking, although they did
not have to want to quit smoking. If they decided to quit, however,
they would receive 8 weeks of treatment with the TNP at no cost.
Participants were included if they were a Latino caregiver (?18
years of age) of a child with asthma (?18 years of age), smoked
?3 cigarettes per day and ?100 cigarettes in their lifetime, and
had not received smoking cessation counseling or pharmacological
treatment for smoking cessation within the past 3 months. This
study was conducted in the years 2004–2007 and received ethical
approval from our institutions’ human subjects institutional review
A total of 213 participants were eligible for the study. Of those,
133 were willing to participate and signed informed consent, 71
were unable to be contacted, 3 were dropped by the project
because of severe substance abuse, and 6 were unwilling to par-
ticipate (Figure 1). Two participants reported quitting before in-
tervention receipt but after randomization. Both had been ran-
domly assigned to the BAM condition. Their data were retained in
all analyses in accordance with intent-to-treat principles.
The ethnic composition was 52.2% Puerto Rican, 22.7% Do-
minican, 10.6% Central American, 6% South American, 2.2%
Mexican, 0.8% Cuban, and 3.7% other. The sample was mostly
female (72.9% women and 27.1% male), the mean age was 36.8
years (SD ? 9.6), 35.1% were employed full- or part-time, 41.3%
reported at least a high school education, 90% reported earning
?$20,000 per year, and 46.2% were married, living with someone,
or engaged. The majority (81.7%) were born outside the United
States, 32% believed their English speaking skills were poor, and,
among the foreign-born, the mean length of time living in the
United States was 14.7 years (SD ? 10.2). The sample had low to
moderate levels of acculturation, as assessed by the Short Accul-
turation Scale for Hispanics (M ? 27.1, SD ? 10.3; Marin,
SPECIAL SECTION: MOTIVATING LATINO SMOKERS TO QUIT
Sabogal, Marin, Otero-Sabogal, & Perez-Stable, 1987). The aver-
age number of cigarettes smoked per day was 10.6 (SD ? 8.4), the
mean Fagerstro ¨m score was 3.8 (SD ? 2.4), indicating moderate
nicotine dependence, and 67.3% of participants reported at least
one 24-hr quit attempt in their lifetime (M ? 2.8, SD ? 10.3). The
average age of the children was 7.1 years (SD ? 4.8), of whom
63% were male and 27% were female. In the previous year, 59.5%
of the children had been to the Emergency Department and 50.5%
had been hospitalized for asthma, indicating a high level of health
care utilization and medical need.
A research assistant traveled to eligible participants’ homes to
obtain written informed consent and administer baseline question-
naires. Participants were then randomly assigned by computer-
generated sequence to receive an intervention based on either the
BAM or the PAM. Participants in both conditions received three
home visits and a 5- to 10-min follow-up call from a bilingual
Latina health educator; a self-help manual (either the American
Lung Association’s Freedom From Smoking Self-Help Manual;
Strecher & Rimer, 2002), or the National Cancer Institute’s Guı ´a
Para Dejar de Fumar: No lo Deje Para Man ˜ana, Deje de Fumar
Hoy [Guide to Quitting Smoking: Don’t Leave It for Tomorrow,
Quit Today]; (Perez-Stable, 2002); and 8 weeks of TNP treatment
at no cost if they were ready to quit. Receipt of the TNP patch
could occur either during or after treatment, depending on when
the participants self-set a quit date (though participants were not
required to set a quit date in order to participate in the trial). An
interactive educational curriculum (“Beating Asthma”) derived
from the learning objectives for asthma education of the National
Heart, Lung and Blood Institute (1997, 2002) was administered
during Visit 1 and a portion of Visit 2. One of the two smoking
interventions (BAM or PAM) was given during the remainder of
Visit 2 and the entire Visit 3.
The BAM intervention followed clinical guidelines for smoking
cessation (Fiore et al., 2000) and was based on social cognitive
theory. The content of the BAM intervention focused on increasing
the smoker’s self-efficacy to quit through teaching problem-
solving and coping skills (e.g., recognition of smoking triggers,
reducing cravings and preventing relapse), overcoming barriers to
quitting, self-monitoring, setting small goals toward quitting, help-
ing the smoker recognize small changes toward quitting smoking,
and reframing past quit attempts as learning experiences (vs.
The goal of the PAM intervention was to increase risk percep-
tion. In this intervention, we used MI as a vehicle to deliver
physiological feedback regarding smoke exposure to oneself and
to one’s child. The counselor provided both verbal and graphical
feedback on the smokers’ carbon monoxide level, symptoms that
are associated with that level, and how quitting smoking could
attenuate disease risk and symptoms. The counselor also provided
both verbal and graphical feedback to the caregiver on the level of
secondhand smoke exposure to the child. Exposure was assessed
through two passive nicotine monitors positioned for 1 week prior
to the feedback: one worn by the child and one placed in the room
in which the child spent the most time. For the air sampler worn by
the child, caregivers were told: “Your child breathed in as much
smoke as if he [or she] smoked ‘X’ number of cigarettes last
week.” For the home sampler, caregivers were told whether the
levels of smoke in their home were low, medium, or high; the
health risks to children with asthma based on this level of expo-
sure; and how these risks could be attenuated or eliminated upon
quitting. Consistent with MI, all feedback was provided with the
Elicit–Provide–Elicit Process, where the counselor elicits the
smoker’s current knowledge about the target topic area, requests
their permission to provide feedback on the topic area, and then
elicits the smoker’s reaction to the feedback (Borrelli, Riekert,
Weinstein, & Cardella, 2007; Rollnick et al 1999).
The counselor also utilized a number of other MI strategies to
help motivate quitting, including discussing the costs and benefits
of quitting smoking, focusing responsibility on the smoker for
deciding to quit, empathizing and resolving ambivalence, and
highlighting cognitive dissonance by helping the smoker view
smoking as seriously discrepant with their goals. If the smoker was
ready to quit, options for quitting were explored, and skill building
and problem solving regarding how to cope with triggers to smoke
were discussed. The intervention was delivered following patient-
centered communication principles, as described in MI procedures
Assessed for Eligibility (n = 2,530)
Not meeting inclusion = 2,399
Eligible (n = 213)
–71 unable to contact
–Refused to participate (n = 6)
–Dropped by project (n = 3)
–Randomized = 133
Allocated to Precaution Adoption
Model (n = 68)
–Received 3 visits + call (n = 42)
–Received 1 visit (n = 12)
–Received 2 visits (n =3)
–Received 3 visits (n = 53)
Allocated to Behavioral Action
Model (n = 65)
–Received 3 visits + call (n = 35)
–Received 1 visit (n = 7)
–Received 2 visits (n = 3)
–Received 3 visits (n = 55)
End of Treatment
Could not contact (n = 14)
Drop-out (n = 2)
Completed (n = 49)
Analyzed (n = 49)
End of Treatment
Could not contact (n = 10)
Drop-out (n = 1)
Completed (n = 49)
Analyzed (n = 49)
Could not contact (n = 3)
Drop-out (n = 0)
Completed (n = 42)
Analyzed (n = 43)
Could not contact (n = 5)
Drop-out (n = 0)
Completed (n = 44)
Analyzed (n = 44)
Could not contact (n = 1)
Drop-out (n = 0)
Completed (n = 46)
Analyzed (n = 46)
Could not contact (n = 1)
Drop-out (n = 0)
Completed (n = 48)
Analyzed (n = 49)
BORRELLI, MCQUAID, NOVAK, HAMMOND, AND BECKER
(e.g., open-ended questions, reflections, summaries, affirmations,
empathy; Rollnick et al., 1999).
The PAM intervention was also designed to be consistent with
the values of the Latino culture (Marin & Van Oss Marin 1991).
Personalismo refers to the importance of intimate relationships
and the value of communication. Detached professional relation-
ships are viewed by Latinos as off-putting. Our use of MI was
intended to foster personalismo, because of its emphasis on
warmth, empathy, and building an egalitarian partnership. Our
counselor also shared minor details of her life and initiated con-
versation prior to counseling in order to make participants feel
comfortable. Familismo, or the centrality and importance of the
family in the Latino culture, was fostered by discussing (a) the
ways in which participants can use their existing support system to
help them quit smoking and (b) how smoke is affecting their
family and the benefits of quitting for their family. Simpatia, or
interpersonal harmony, was fostered through the MI techniques of
reflective listening and avoiding confrontation. For example, when
the feedback about the child’s exposure was given, empathic
listening and reflections were used to decrease the potential for
denial, defensiveness, and guilt after hearing the exposure feed-
back. We addressed participants’ feelings of guilt regarding sec-
ondhand smoke exposure to their child by conveying to them that
they did not previously have this information and, now that they
do, they can make a decision about what, if anything, they would
like to do about their smoking.
Training, Evaluation of Skill Acquisition,
and Internal Validity
The Latina health educator was trained in the protocol and in MI
through self-study, didactics, role plays, and video. Trainers were
licensed clinical psychologists; one was certified in MI and the
other was certified in asthma education. Skill acquisition was
determined by observation of counseling behaviors with standard-
ized patients. Treatment fidelity was maintained through adher-
ence to best practice guidelines (Borrelli, Sepinwall, et al., 2005)
and included a weekly review of a subsample of audiotaped
counseling sessions, patient exit interviews, and counselor docu-
mentation of time spent discussing smoking and components de-
livered. The health educator met with trainers on a weekly basis for
Participants completed self-report assessments administered by
research assistants who were blind to treatment condition. The
assessments occurred at baseline, end of treatment (typically
within 2 weeks of the third and final counseling visit), and 2 and
3 months following end of treatment. Participants received pay-
ment for completing each assessment and returning air samplers. A
maximum amount of $55 could be obtained.
Demographics and smoking history.
gender, education, income, ethnicity, birth country, number of
cigarettes smoked per day, number of years of smoking, previous
quit attempts, and number of household smokers. The Fagerstro ¨m
Test for Nicotine Dependence (Heatherton, Kozlowski, Frecker, &
Fagerstro ¨m, 1991) measured nicotine dependence. This measure is
internally consistent (? ? .70; Pomerleau, Carton, Lutzke, Fless-
Measures included age,
land, & Pomerleau, 1994) and correlated with several objective
measures (Fagerstro ¨m & Schneider, 1989).
Motivation to quit.
We assessed motivation to quit with the
Contemplation Ladder, a one-item, 11-point scale of motivation
(0 ? no thought of quitting and 10 ? taking action to quit), which
has demonstrated reliability and validity (Abrams & Biener, 1992;
Biener & Abrams, 1991).
Asthma functional severity scale.
Asthma Functional Severity Scale assesses symptom frequency
and activity limitation due to asthma. Significant associations have
been found between the AFSS and school absences, medication
use, and medical visits for asthma (Rosier et al., 1994). The scale
has adequate internal consistency (? ? .72; Koinis-Mitchell et al.,
2007) and has been translated and used successfully with Latinos
(Koinis-Mitchell et al., 2007).
Short acculturation scale for Hispanics.
(Marin et al., 1987) is .92. The scale is correlated with length of
residence in the United States, respondents’ generation, and re-
spondents’ self-evaluation of their acculturation (Marin et al.,
We objectively measured secondhand
smoke with passive nicotine monitors at baseline and at 3 months
after the end for treatment. At each time point, two monitors were
positioned: one in the room in which the child spent the most time
and one worn by the child. The monitors measure nicotine as a
tracer for the amount of ambient secondhand smoke. Nicotine
collected in the monitors was analyzed by gas chromatography.
The monitors used in the current study have been tested in an
environmental chamber (Hammond & Leaderer, 1987) and in 96
homes (Leaderer & Hammond, 1991). This method has been
validated in an intercomparison study (Caka et al., 1990) demon-
strating accurate detection of nicotine. The nicotine concentration
measured on the personal sampler was used, together with the
normal breathing rates of children, the side-stream emissions of
nicotine, and the ratio of side-stream to mainstream emissions of
N-nitrosodimethylamine (NNMA), to calculate the equivalent
number of cigarettes that one would need to smoke to have the
same intake of NNMA as the passive exposure experienced that
week: cigarette equivalents ? [nicotine] ? volume of air
breathed ? secondhand smoke (NNDA)/mainstream smo-
ke(NNDA)/secondhand smoke(nicotine) (Hammond, Sorensen,
Youngstrom, & Ockene, 1995).
Smoking status was assessed at the end of
treatment and 2 and 3 months later. Consistent with recommenda-
tions from the Society of Research on Nicotine and Tobacco, we
defined continuous abstinence as no smoking, not even a puff,
since the last contact and 7-day point prevalence abstinence as no
smoking in the 7 days prior to the current assessment contact
(Hughes et al., 2003). Expired air CO testing (CO Ecolyzer;
Bedfont Scientific Ltd., Medford, NJ) was used to verify self-
reported abstinence (?10 ppm ? abstinence). Two participants
who self-reported abstinence had CO readings ?10 ppm and were
recoded as smokers.
Rosier et al.’s (1994)
To assess group differences on smoking outcomes, we con-
ducted analyses with two methods: a sample that included all
available cases and an intention-to-treat sample, whereby missing
SPECIAL SECTION: MOTIVATING LATINO SMOKERS TO QUIT
values were coded as “smoking.” Effect sizes were computed as d
values (Cohen, 1988). The initial sample size of 133 had sufficient
power (0.80) to detect a 20-percentage-point difference in rates of
abstinence between participants in the BAM and PAM interven-
tions, though attrition limited the available power at each wave.
After accounting for attrition, study power was reduced for the
sample N of 98 (power ? 0.68), for the N ? of 87 (power ? 0.63),
and for the N of 95 (power ? 0.67) at end of treatment, 2-month,
and 3-month follow-ups, respectively.
We analyzed all study outcomes, except where otherwise noted,
with Generalized Estimating Equations (GEE) PROC GENMOD
in SAS. Each model consisted of fixed effects for time and
treatment condition, as well as an interaction between assessment
time and treatment condition. Time was effect coded to estimate
separate post hoc contrasts and capture the effect of various
functional forms of the time by condition relationship between and
within conditions. The within-time (e.g., cross-sectional) signifi-
cant and nonsignificant smoking outcome contrasts are presented
here to show the magnitude of treatment effects on smoking
behavior at each follow-up assessment. Binary outcomes were
modeled with a logit link, and an identify link was specified for
continuous outcomes. Of note is that, in GEE, the regression
coefficients (e.g., odds ratios for dichotomous outcomes) are in-
terpreted as the population-averaged response for observations
sharing values on model covariates. The robust standard errors are
presented for results from the GEE regression models. We report
all statistical tests using a conventional p ? .05.
The treatment groups were not significantly different on any
baseline variables, even after we accounted for multiple testing
using a Bonferroni correction (Table 1). Only 55% of the sample
reported at baseline that they were ready to quit within 30 days
(51.6% of the BAM participants and 58.8% of PAM participants,
p ? .05).
Treatment exposure and retention.
cally significant differences between BAM and PAM interventions
in attrition over time (Figure 1). Assessment completion rates were
as follows: 73% (end of treatment), 65% (2-month follow-up), and
71% (3-month follow-up). There were no significant differences
between groups in treatment exposure, and a large proportion of
participants received all three program visits: 77.9% of participants
in the PAM condition and 84.6% of participants in the BAM
condition (a smaller percentage received three visits plus the brief
call: 61.7% of PAM participants and 54.0% of BAM participants).
The vast majority of the sample perceived the health educator to be
“very helpful” (91%), 94% felt that the program would be “very
helpful” to other caregivers of children with asthma, and 97% were
“very satisfied” with the care provided. No significant differences
in these satisfaction items were observed between conditions.
We assessed TNP use since the last contact. No
significant differences in TNP use emerged between conditions.
By the end of treatment, 5% of participants in both BAM and PAM
interventions had used the TNP; at 2 months, 67% of those in the
BAM group and 65% of those in the PAM group had used TNP
since the end of treatment; and at 3 months, 65% of BAM partic-
ipants and 50% of PAM participants had used TNP since the
There were no statisti-
smoking outcomes using all available cases and intention-to-treat,
respectively. For continuous abstinence outcomes including all
available cases at the 2-month follow-up, participants in the PAM
group were more than twice as likely (31.8%) as those in the BAM
group (14.2%) to report continuous abstinence (OR ? 2.80, 95%
Tables 2 and 3 present the results on
Demographics and Smoking History by Treatment Group
Total sampleBAM PAM
M or %
SDM or %
SDM or %
Child age (years)
Parent age (years)
% Female (caregiver)
Smoking rate (cigarettes/day)a
Fagerstro ¨m score
No. of 24-hr lifetime quits
Motivation to quit
% Born in the United States
% Employed (full or part time)
% High school graduate
Asthma morbidity score
Home environmental tobacco smoke monitor
Child environmental tobacco smoke monitor
No. of household smokers
% Who never tried to quit
aTwo participants in the BAM reported quitting prior to their baseline assessment.
BAM ? behavioral action model; PAM ? precaution adoption model.
BORRELLI, MCQUAID, NOVAK, HAMMOND, AND BECKER
CI ? 0.95–8.18, Cohen’s d ? .42), though the results did not reach
statistical significance (p ? .059). Similar results were found with
intent-to-treat analyses: 20.5% for PAM vs. 9.2% for BAM (OR ?
2.54; CI ? 0.91–7.10). At the 3-month follow-up, participants
receiving the PAM intervention were more likely (19.1%) than
those receiving the BAM group (12.3%) to be continuously absti-
nent in intent-to treat-analyses (OR ? 1.68; 95% CI ? 0.64–4.37)
as well as in analyses including all available cases (28.2% contin-
uously abstinent in PAM vs. 17.7% in BAM; OR ? 1.82; 95%
CI ? 0.67–4.94), although the differences were not statistically
significant (ds ? .18 and .25, respectively). No significant changes
over time, condition, or Time ? Condition were observed.
Seven-day point prevalence abstinence.
PAM intervention had higher 7-day point prevalence abstinence
rates than did those in BAM condition over all three assessments
(Tables 1 and 2), but the differences were not significant. When all
available cases were included in the analyses, the effect sizes were
as follows: d ? .19 at end of treatment, d ? .28 at 2-month
follow-up, and d ? .18 at 3—month follow-up. Using intent–to-
treat analyses, we obtained the following effect sizes: d ? .15 at
end of treatment, d ? .20 at 2 months, and d ? .08 at 3 months.
According to the longitudinal analyses, quit rates significantly
increased over time for both conditions, ?2(2) ? 13.52, p ? .01.
There was no main effect of treatment condition nor was there an
interaction between treatment condition and time.
Effect of acculturation.
There was no significant effect of
acculturation on smoking status at any time point, and the inter-
Participants in the
action between acculturation and treatment condition on smoking
status was not significant.
Objective secondhand smoke exposure.
of the home monitors were returned, and 97.7% of these were in
good enough condition to be analyzed; 96.2% of the child monitors
were returned, among which 99.2% were in good condition. At the
3 month follow-up, 61.7% of the home monitors were returned,
98.8% of which were in good condition, and 60.9% of the child
monitors were returned, 100% of which in good condition. Out-
come analyses for secondhand smoke exposure were adjusted for
seasonality (fall/winter vs. spring/summer), with the expectation
that cold-weather seasons would increase exposure because of
limited options for air circulation (e.g., open windows and doors)
and outdoor activities. We also adjusted for the total number of
smokers in the home at baseline. Secondhand smoke concentra-
tions, as assessed by the home monitors, significantly decreased
from pretreatment to the 3 month follow-up in the BAM condition,
(baseline M ? 1.07, SE ? 0.19, and 3-month M ? 0.28, SE ?.11
?2(1) ? 8.41, p ? .01), whereas the decrease observed in the PAM
condition was nonsignificant (baseline M ? 0.73, SE ? 0.12, and
3-month M ? 0.60, SE ? 0.19, ?2(1) ? 0.09, p ? .05; see
Figure 2). Changes in secondhand smoke concentrations as assessed
by the child monitors, however, were not statistically significant.
The finding that participants in the BAM condition had greater
household secondhand smoke reductions in home concentrations
than did those in the PAM condition was unexpected, given that
those in the latter condition attained higher quit rates. We inves-
tigated the possibility that smokers in the BAM condition might
have adopted a strategy that involved reducing their levels of
smoking rather than quitting altogether. We conducted post hoc
comparisons, comparing pre- to post–secondhand smoke reduction
between conditions by smoking status. Among those who had
smoked in the past 7 days at the 3-month assessment (nonquitters), a
significant Assessment Time ? Condition interaction was present,
?2(1) ? 4.24, p ? .03, such that BAM nonquitters had larger reduc-
tions in home concentrations (baseline M ? 1.24, SE ? 0.28, and
3-monthM?0.50,SE?.17;?2(1)?6.01,p ? .014) in comparison
with PAM nonquitters, who had no significant change over time
(baseline M ? 0.64, SE ? 0.19, and 3-month M ? 0.70, SE ?
0.25; ?2(1) ? 0.04, p ? .05). BAM nonquitters also self-reported
a significantly (p ? .05) larger reduction in number of cigarettes
smoked in front of the child (baseline M ? 5.91 and 3-month M ?
1.97) compared with PAM nonquitters (baseline M ? 2.22 and
At baseline, 96.2%
Smoking Cessation Outcome Analyses: All Available Cases
BAM% (n) PAM% (n)
7-day point prevalence abstinence
8.1% (49) 14.2% (49)
25.5% (43)38.6% (44)
24.4% (49) 32.6% (46)
End of treatment
BAM ? behavioral action model; PAM ? precaution adoption model; OR ? odds ratio; CI ?
Smoking Cessation Outcome Analyses: Intent-to-Treat
7-day point prevalence abstinence
End of treatment
adoption model; OR ? odds ratio; CI ? confidence interval.
N ? 133. BAM ? behavioral action model; PAM ? precaution
SPECIAL SECTION: MOTIVATING LATINO SMOKERS TO QUIT
3-month M ? 1.35). Therefore, it appears that, despite their lower
quit rates, BAM participants might have had lower secondhand
smoke household concentrations than those in the PAM condition
because the nonquitters reduced their smoking around their child.
The child’s level of functional morbidity
due to asthma decreased significantly (p ? .001) in both condi-
tions over time, but these changes occurred at different time points.
The change occurred in the BAM condition between baseline and
end of treatment: baseline mean ? 1.55, SE ? 0.13, and end of
treatment mean ? 0.98, SE ? 0.13, ?2(1) ? 15.62, p ? .001. The
statistically significant change in asthma morbidity occurred in the
PAM condition between the end of treatment and 2 months, during
the time when participants were quitting smoking: end of treatment
M ? 1.26, SE ? 0.16 and 2-month M ? 0.71, SE ? 0.13,
?2(1) ? 10.20, p ? .01.
Our study makes a number of contributions to the smoking
cessation literature. Most research on smoking cessation for Lati-
nos has focused on Mexican Americans; only one other such trial
with the Latino population was conducted in the Northeast, where
the majority of Latinos are from the Caribbean. This is important
because there are differences in smoking patterns and prevalence,
as well as in asthma incidence and severity, among Latino sub-
groups. For example, Puerto Rican children have higher asthma
prevalence and morbidity and poorer asthma outcomes than do
other racial and ethnic groups (Lara et al., 2006; Loyo-Berrios,
Orengo, & Serrano-Rodriguez, 2006). Our study also makes a
contribution because the vast majority of studies focus on house-
hold secondhand smoke reduction rather than on smoking cessa-
tion. Furthermore, no smoking cessation studies have utilized an
all-Latino sample of caregivers of children with asthma. A unique
aspect of our study was that we advertised that it was not necessary
for smokers to want to quit in order to qualify for participation in
the study but that they simply had to agree to talk about their
smoking and receive asthma education. Therefore, our sample
consisted of smokers at all levels of motivation to quit, not only
those who were seeking treatment for smoking cessation.
Our treatment based on enhancing risk perception (PAM)
achieved higher smoking cessation rates than did our comparison
treatment based on building self-efficacy to quit smoking (BAM).
The differences between the groups approached, but did not attain,
statistical significance, though confidence in the results is bol-
stered by the consistency of findings across analyses. Results
might have fallen short of statistical significance for several rea-
sons. First, although our level of power to detect differences
between the groups was in a respectable range, it did not attain the
traditional .80 level. Recruitment and retention were lower than
expected, potentially due to the many immigration checks in the
area that occurred during the time of the study. Several of our
participants were deported during the course of the study. Second,
statistical significance is easier to achieve with the presence of a
true control group. We did not have a no-treatment control or
assessment-only group but rather chose to compare two different
treatments. This is a stronger test of the hypothesis of whether
tailored treatments improve quit rates over and above treatments
based on existing clinical guidelines for smoking cessation (Fiore
et al., 2000). We hypothesized that Latino caregivers need tailored
approaches that take into account both cultural values and levels
readiness to quit. We theorized that caregivers who continued to
smoke despite their child’s asthma would need an intervention that
focused on augmentation of risk perception for self and child, not
simply an intervention that provided problem solving and educa-
tion about how to quit. Therefore, the finding that the PAM
outperformed the BAM suggests that clinical guidelines alone may
have only limited efficacy for this population.
Our results are clinically significant because both groups at-
tained relatively high quit rates, despite the fact that we targeted a
population that has traditionally been hard to reach and treat (King
et al., 1997: 36.6% of the sample had never tried to quit before
entering the trial and 45.0% were not considering quitting within
30 days of study entry. The integration of smoking cessation into
well-accepted interventions like asthma education can facilitate
proactive reach to smokers who might not spontaneously seek help
to quit smoking or who do not have ready access to primary care
or preventive health services. Reactive interventions, by contrast,
precaution adoption model. 3-month ? 3-month follow-up.
Home concentration levels of secondhand smoke. BAM ? behavioral action model; PAM ?
BORRELLI, MCQUAID, NOVAK, HAMMOND, AND BECKER
may not reach those most at risk. Fish, Wilson, Latini, and Starr
(1996), for example, measured the attendance of smokers at
asthma education programs and found that it varied by smoking
status: Nonattendance rates were 24%, 42%, and 78% in non-
smoker families, one-smoker families, and families with two or
more smokers. Indeed, a meta-analysis found that a greater per-
centage of home-based interventions (88%) than physician-based
interventions (40%) resulted in significant reductions in second-
hand smoke; Gehrman & Hovell, 2003).
An unexpected finding was that the BAM intervention yielded
greater reductions in secondhand smoke exposure in the home
concentrations (though not in child concentrations) than did the
PAM intervention, despite the finding that participants in the latter
condition had higher quit rates. Post hoc analyses revealed that this
effect was largely due to two findings: (a) Nonquitters in the BAM
condition reduced the level of secondhand smoke in their homes
more than did PAM nonquitters, and (b) nonquitters in the BAM
condition, compared with those in the PAM condition, reported
that they were more likely to reduce the number of cigarettes
smoked by themselves and others in front of their child than were
PAM nonquitters. It is possible that BAM participants made extra
efforts to reduce secondhand smoke exposure to others in the
household in lieu of quitting.
However, the reduction of secondhand smoke did not translate
to reduced asthma morbidity in the BAM condition: Children in
the PAM condition had reduced asthma morbidity in the posttreat-
ment period, whereas children in the BAM condition did not.
Because of the short-term nature of the study, we could not
determine whether quitting smoking caused reductions in the chil-
dren’s asthma. Longer term studies are needed to verify the co-
variation between smoking cessation and improvements in asthma
Only the PAM treatment was designed to be consistent with
core Latino values (e.g., personalismo, familismo, simpatia), al-
though both BAM and PAM interventions had surface tailoring
(e.g., the interventions were delivered by a Latina health educator,
and the counseling was provided in either English or Spanish).
Whether surface tailoring was sufficient to influence the cultural
relevancy of the two interventions and impact quit rates is equiv-
ocal. We could speculate that the higher quit rates achieved by
PAM participants were likely due to the content of the intervention
rather than to the extra tailoring to the core values, because there
were no differences between the two interventions in satisfaction
with our program. Though meta-analyses have found that mental
health treatments are four times more effective when culturally
modified for a specific group and when attentive to cultural con-
text and values (Griner & Smith, 2006), there is little guidance on
the extent of cultural modifications needed to achieve true cultural
tailoring. Alternatively, perhaps our strategic inclusion of Latino
values in the PAM intervention had a synergistic effect with the
risk feedback to produce comparatively larger quit rates in this
condition compared with the BAM condition. Incorporating Latino
values has been shown to be critical to increasing the likelihood of
Latino engagement in treatment (Anez, Silva, Paris, & Bedregal,
2008). Without such treatment alliance, feedback on risks of
smoking to self and child might have been met with denial and
The U.S. Census Bureau projects that by the year 2030, Latinos
will constitute more than 73 million of those living in the United
States, representing 20% of the population (U.S. Census Bureau,
2004). Given Latinos’ higher rates of asthma, greater asthma
morbidity, and lower likelihood of seeking counseling services
(U.S. Department of Health and Human Services, 2001), it will
become increasingly important to proactively reach this population
through innovative and creative channels, such as home-based
intervention, interventions in schools, and development of alli-
ances with community agencies that target Latinos. Primary care
providers, asthma specialists, hospital emergency room staff, and
nursing agencies should be prepared to address smoking in this
population during the medical encounter. The child’s asthma ex-
acerbation may provide a teachable moment during which care-
givers who smoke may be more likely to attend to smoking
cessation messages. Providing treatment that is focused on the
health needs of the family, and delivered in a culturally tailored
manner, has the potential to address health-care disparities for
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Received February 2, 2009
Revision received June 26, 2009
Accepted June 29, 2009 ?
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